NCLEX RN Exam Review Answers

NCLEX RN Exam Review Answers Related

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The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

  • A. Diarrhea
  • B. Projectile vomiting
  • C. Regurgitation of feedings
  • D. Constipation
Correct Answer: C

Rationale: Hirschsprung's disease, also known as congenital aganglionosis or aganglionic megacolon, is characterized by the absence of ganglion cells in the rectum and other parts of the affected intestine. Clinical manifestations of Hirschsprung's disease include chronic constipation with pellet-like or ribbon-like foul-smelling stools, delayed or absent passage of meconium in the neonatal period, bowel obstruction (especially in the neonatal period), abdominal pain and distention, and failure to thrive. In the case of an infant with suspected Hirschsprung's disease, regurgitation of feedings is a sign that may have led the mother to seek healthcare. This symptom can be associated with the bowel dysfunction and obstruction seen in Hirschsprung's disease. Options A, B, and D are not typically associated with Hirschsprung's disease. Diarrhea is not a common symptom, projectile vomiting is not a typical presentation, and constipation, while a symptom of the disease, is not the sign that would most likely prompt a visit to seek healthcare in an infant suspected of having Hirschsprung's disease.

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A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?

  • A. Apply ointment to the skin to avoid moisture
  • B. Wash the area gently with water and pat dry
  • C. Use a mild antiseptic soap to wash the area and pat dry
  • D. Apply talcum powder to keep the skin dry
Correct Answer: B

Rationale: For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.

After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?

  • A. Urinary incontinence
  • B. Impaired tissue integrity
  • C. Inability to suck and swallow
  • D. Lack of knowledge about the disease (parents)
Correct Answer: B

Rationale: In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.

The parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism are provided with discharge instructions by the nurse. Which statement by the parents indicates the need for further instruction?

  • A. I'll check his temperature.
  • B. I'll give him medication so he'll be comfortable.
  • C. I'll check his voiding to be sure there's no problem.
  • D. I'll let him decide when to return to his play activities.
Correct Answer: D

Rationale: Cryptorchidism is a condition where one or both testes fail to descend into the scrotal sac. Orchiopexy, a surgical correction, may be required. After surgery, it is crucial to restrict vigorous activities for 2 weeks to promote healing and prevent injury. Allowing the child to decide when to return to play activities may lead to delayed healing and increased risk of injury, as 2-year-olds typically want to be active. Checking the child's temperature, administering analgesics as needed, and monitoring urine output are important postoperative care measures to ensure recovery and detect complications early. Therefore, the statement indicating the need for further instruction is the one related to letting the child decide when to resume play activities.

Renal failure is broadly divided into specific categories. Which type is the type II diabetic patient most likely to experience secondary to diabetes?

  • A. Acute renal failure (ARF)
  • B. Intermittent renal failure (IRF)
  • C. Chronic renal failure (CRF)
  • D. Reversible renal failure (RRF)
Correct Answer: C

Rationale: Diabetic nephropathy is a common complication in type II diabetic patients, leading to chronic renal failure (CRF). Chronic renal failure (CRF) and acute renal failure (ARF) are the two main categories of renal failure. CRF can result from various conditions including diabetic nephropathy, chronic glomerulonephritis, chronic pyelonephritis, polycystic kidney disease, connective tissue disorders, and amyloidosis. Unlike acute renal failure, chronic renal failure is irreversible. Timely treatment of ARF can often lead to reversibility, but CRF may require renal replacement therapy (RRT) or kidney transplant. Therefore, the correct answer is chronic renal failure (CRF). Intermittent renal failure (IRF) and reversible renal failure (RRF) are not recognized medical terms for distinct types of renal failure, making choices B and D incorrect.

Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?

  • A. Pickle
  • B. Wheat toast
  • C. Baked chicken
  • D. Steamed vegetables
Correct Answer: A

Rationale: In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.

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